Conventional regimen: The total daily insulin dose is administered as a mixture of rapid/short-acting and intermediate-acting insulins in 1-2 injections. Twice daily injections are preferred for better glycemic control. With the 2-injection regimen, generally two-thirds of the daily dose is given before breakfast and one-third is given before the evening meal.

Intensive regimen: The total daily dose is administered as 3 or more injections or by continuous subcutaneous infusion to cover basal and pre-meal bolus insulin requirements. The basal requirement is approximately 30-50% of the total dose, given as intermediate or long-acting insulin (NPH, zinc, extended zinc, lispro-protamine, glargine), 1-2 times daily. Meal boluses are approximately 50-70% of the total dose, given as rapid/short-acting insulin (regular, aspart, lispro) 2-5 times daily before meals. Common regimens include injections of rapid/short acting insulin before each meal along with injections of intermediate or long-acting insulin in the morning and/or evening. Dosage adjustments are made to achieve target blood glucose levels and are based on frequent blood glucose measurements, diet and exercise levels.

Conventional regimen: The total daily insulin dose is administered as a mixture of rapid/short-acting and intermediate-acting insulins in 1-2 injections. Twice daily injections are preferred for better glycemic control. With the 2-injection regimen, generally two-thirds of the daily dose is given before breakfast and one-third is given before the evening meal.

Intensive regimen: The total daily dose is administered as 3 or more injections or by continuous subcutaneous infusion to cover basal and pre-meal bolus insulin requirements. The basal requirement is approximately 30-50% of the total dose, given as intermediate or long-acting insulin (NPH, zinc, extended zinc, lispro-protamine, glargine), 1-2 times daily. Meal boluses are approximately 50-70% of the total dose, given as rapid/short-acting insulin (regular, aspart, lispro) 2-5 times daily before meals. Common regimens include injections of rapid/short acting insulin before each meal along with injections of intermediate or long-acting insulin in the morning and/or evening. Dosage adjustments are made to achieve target blood glucose levels and are based on frequent blood glucose measurements, diet and exercise levels.

Usual Adult Dose for Diabetes Type 2

Regular insulin is a short-acting insulin and should be injected within 30-60 minutes before a meal.

Diet and lifestyle modifications are recommended as initial treatment for type II diabetes, followed by oral agents. Insulin may be considered if patients are very hyperglycemic or symptomatic and/or not controlled with oral agents. Insulin may exacerbate obesity, further increase insulin resistance, and increase the frequency of hypoglycemia.

Conventional regimen:
Initial dose, monotherapy: Total daily requirement: 0.1 unit/kg/day subcutaneously. When insulin is used alone, twice daily injections are recommended for better glycemic control. The total daily insulin dose is administered as a mixture of rapid/short-acting and intermediate-acting insulins in 1-2 injections. With the 2-injection regimen, generally two-thirds of the daily dose is given before breakfast and one-third is given before the evening meal. Once daily injections are sometimes used in children with suboptimal compliance; however, this may lead to more nocturia, fasting hyperglycemia, morning glucosuria, and a risk of ketoacidosis if the doses are missed.
Maintenance dose, monotherapy: Total daily insulin requirements may progress to 1.5-2.5 units/kg or higher in patients with obesity and insulin resistance.

Intensive regimen:
The necessity for and efficacy of intensive insulin therapy in type II diabetes has been controversial. The total daily dose is administered as 3 or more injections or by continuous subcutaneous infusion to cover basal and pre-meal bolus insulin requirements. This method may be appropriate for closely supervised and highly motivated older children or adolescents who are able to inject their insulin, monitor their blood glucose, and recognize hypoglycemia. The basal requirement is approximately 30-50% of the total dose, given as intermediate or long-acting insulin (NPH, zinc, extended zinc, lispro-protamine, glargine), 1-2 times daily. Meal boluses are approximately 50-70% of the total dose, given as rapid/short-acting insulin (regular, aspart, lispro) 2-5 times daily before meals. Common regimens include injections of rapid/short acting insulin before each meal along with injections of intermediate or long-acting insulin in the morning and/or evening. Dosage adjustments are made to achieve target blood glucose levels and are based on frequent blood glucose measurements, diet and exercise levels.
Initial dose, monotherapy: 0.5-1.5 unit/kg/day subcutaneously.
Maintenance dose, monotherapy: Total daily insulin requirements may progress to 2.5 units/kg or higher in patients with obesity and insulin resistance.

Usual Adult Dose for Hyperkalemia

Usual Adult Dose for Insulin Resistance

Total daily insulin requirements range from 0.7 to 2.5 units/kg. Concentrated insulin (500 units/mL) may be used for patients taking more than 200 units/day to allow for reasonable subcutaneous dose volumes.

Conventional regimen: The total daily insulin dose is administered as a mixture of rapid/short-acting and intermediate-acting insulins in 1-2 injections. Twice daily injections are recommended for better glycemic control. With the 2-injection regimen, generally two-thirds of the daily dose is given before breakfast and one-third is given before the evening meal. Once daily injections are sometimes used in children with suboptimal compliance; however, this may lead to more nocturia, fasting hyperglycemia, morning glucosuria, and a risk of ketoacidosis if the doses are missed.

Intensive regimen: The total daily dose is administered as 3 or more injections or by continuous subcutaneous infusion to cover basal and pre-meal bolus insulin requirements. This method may be appropriate for closely supervised and highly motivated older children or adolescents who are able to inject their insulin, monitor their blood glucose, and recognize hypoglycemia. The basal requirement is approximately 30-50% of the total dose, given as intermediate or long-acting insulin (NPH, zinc, extended zinc, glargine), 1-2 times daily. Meal boluses are approximately 50-70% of the total dose, given as rapid/short-acting insulin (regular, lispro) 2-5 times daily before meals. Common regimens include injections of rapid/short acting insulin before each meal along with injections of intermediate or long-acting insulin in the morning and/or evening. Dosage adjustments are made to achieve target blood glucose levels and are based on frequent blood glucose measurements, diet and exercise levels.

Usual Pediatric Dose for Diabetes Type 2

Regular insulin is a short-acting insulin and should be injected within 30-60 minutes before a meal.

Diet and lifestyle modifications are recommended as initial treatment for type II diabetes, followed by oral agents (metformin). Insulin may be considered if children are very hyperglycemic or symptomatic and/or not controlled with oral agents. Insulin may exacerbate obesity, further increase insulin resistance, and increase the frequency of hypoglycemia.

Conventional regimen:
Initial dose, monotherapy: Total daily requirement: 0.1 unit/kg/day subcutaneously. When insulin is used alone, twice daily injections are recommended for better glycemic control. The total daily insulin dose is administered as a mixture of rapid/short-acting and intermediate-acting insulins in 1-2 injections. With the 2-injection regimen, generally two-thirds of the daily dose is given before breakfast and one-third is given before the evening meal. Once daily injections are sometimes used in children with suboptimal compliance; however, this may lead to more nocturia, fasting hyperglycemia, morning glucosuria, and a risk of ketoacidosis if the doses are missed.
Maintenance dose, monotherapy: Total daily insulin requirements may progress to 1.5-2.5 units/kg or higher in patients with obesity and insulin resistance.

Intensive regimen:
The necessity for and efficacy of intensive insulin therapy in type II diabetes has been controversial. The total daily dose is administered as 3 or more injections or by continuous subcutaneous infusion to cover basal and pre-meal bolus insulin requirements. This method may be appropriate for closely supervised and highly motivated older children or adolescents who are able to inject their insulin, monitor their blood glucose, and recognize hypoglycemia. The basal requirement is approximately 30-50% of the total dose, given as intermediate or long-acting insulin (NPH,zinc, extended zinc, glargine), 1-2 times daily. Meal boluses are approximately 50-70% of the total dose, given as rapid/short-acting insulin (regular, lispro) 2-5 times daily before meals. Common regimens include injections of rapid/short acting insulin before each meal along with injections of intermediate or long-acting insulin in the morning and/or evening. Dosage adjustments are made to achieve target blood glucose levels and are based on frequent blood glucose measurements, diet and exercise levels.
Initial dose, monotherapy: 0.5-1.5 unit/kg/day subcutaneously.
Maintenance dose, monotherapy: Total daily insulin requirements may progress to 2.5 units/kg or higher in patients with obesity and insulin resistance.

Usual Pediatric Dose for Insulin Resistance

True insulin resistance is rare in children. Daily requirements may be greater than 2 units/kg. Extreme insulin resistance with insulin requirements greater than 10 units/kg/day has been reported in children with acanthosis nigricans and polycystic ovaries.

Concentrated insulin (500 units/mL) may be used for patients taking more than 200 units/day to allow for reasonable subcutaneous dose volumes.

Liver Dose Adjustments

Dose Adjustments

Daily insulin requirements may be higher during illness, stress, pregnancy, in obese patients, trauma, during concurrent use with medications having hyperglycemic effects, or after surgery, and lower with exercise, weight loss, calorie restricted diets, or during concurrent use of medications having hypoglycemic effects. Total daily doses should not be adjusted by more than 10% increments.

Supplemental doses may be prescribed during illness or to correct high preprandial blood glucose.

Dosage adjustments may be required when the brand, type, or species of insulin is changed.

Precautions

Patients should be educated on how to recognize symptoms of acidosis and hypoglycemia and what to do if they occur.

Intensive insulin therapy and subcutaneous insulin pumps should be avoided in patients who are unable or unwilling to comply with frequent blood glucose testing and injection requirements (alcohol or drug abuse, psychiatric disorders), who have cognitive or developmental issues (small children), and those who are prone to developing severe hypoglycemia or in whom hypoglycemia could be potentially fatal, e.g., adrenal or pituitary insufficiency, counterregulatory insufficiency, autonomic neuropathy, concurrent use of beta adrenergic blocking agents, coronary or cerebral vascular disease.

Regular insulin or mixtures containing it should be given 30-60 minutes before a meal.

When mixing with other insulins, regular insulin should be drawn up into the syringe first. Do not give mixtures IV or IM.

Do not give buffered insulin or concentrated insulin (500 units/mL) by IV .

Unbuffered regular insulin and isophane (NPH) insulin may be mixed together in any proportion and must be used within 14 days if stored at room temperature and within 3 weeks if refrigerated. Buffered regular insulin and isophane (NPH) insulin may be mixed but must be used immediately.

Mixing unbuffered regular insulin and zinc insulins is not recommended because zinc will complex with regular insulin and increase its duration of action. If mixed, they should be used immediately.

Buffered regular insulin and zinc insulins should not be mixed because zinc phosphate may precipitate.

Buffered regular insulin is preferred for insulin pumps; however, it should not be mixed with any other insulin because precipitation may occur.

Concentrated insulin (500 units/mL) should be dosed with extreme caution because irreversible insulin shock may occur with overdosage.

Dialysis

Insulin is not significantly removed by either peritoneal or hemodialysis

Other Comments

At least twice weekly blood glucose monitoring is recommended for type I and II diabetes on conventional insulin therapy. Blood glucose is measured 3 or more times daily before meals during intensive insulin regimens. More frequent monitoring is necessary during illness or stress.

Urine ketone testing is recommended for patients with type I diabetes if they develop symptoms of colds, influenza, nausea, vomiting, or other illnesses, polyuria, or if blood glucose levels are unexpectedly high or inconsistent.

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